Problem-based learning curriculum disconnect on diversity, equitable representation, and inclusion

Diversity, equity, and inclusion (DEI) mission statements continue to be adopted by academic institutions in general, and by dental schools around the globe in particular. But DEI content seems to be under-developed in dental education. The objectives of this study were two-fold: to extract information from all the PBL cases at University of British Columbia’s Faculty of Dentistry curriculum in terms of the diversity, equitable representation, and inclusion of patient and provider characteristics, context, and treatment outcomes; and; to compare these findings with the composition of the British Columbia census population, dental practice contextual factors, and the evidence on treatment outcomes within patient care. Information from all the 58 PBL cases was extracted between January and March 2023, focusing on patient and provider characteristics (e.g., age, gender, ethnicity), context (e.g., type of insurance), and treatment outcomes (e.g., successful/unsuccessful). This information was compared with the available literature. From all the 58 PBL cases, 0.4% included non-straight patients, while at least 4% of BC residents self-identify as non-straight; there were no cases involving First Nations patients although they make up 6% of the British Columbia population. Less than 10% of the cases involved older adults who make up almost 20% of the population. Only Treatments involving patients without a disability were 5.74 times more likely to be successful compared to those involving patients with a disability (p<0.05). The characteristics of the patients, practice context, and treatment outcomes portrayed in the existing PBL cases seem to differ from what is known about the composition of the British Columbia population, treatment outcome success, and practice context; a curriculum disconnect seems to exist. The PBL cases should be revised to better represent the population within which most students will practice.


Introduction
Diversity, equity, and inclusion (DEI) mission statements continue to be adopted by academic institutions in general, and by dental schools around the globe in particular [1][2][3][4].The term "diversity" is usually used to refer to differences among individuals, including but not limited to race, ethnicity, disability, nationality, socioeconomic stratum, gender identity, and sexual orientation [5].The term "equity" refers to the goal of fair and unbiased treatment and representation of all individuals of a group or community regardless of their diversity.The term "inclusion" refers to the extent to which any individual or group are or feel respected, supported, and engaged in a given environment [6].Accordingly, DEI statements within dental schools focus solely on people-students, staff, faculty members, and patients-so they feel safe, welcomed, valued, represented, and heard [7].In turn, there are a number of initiatives aimed at increasing representation of students, patients, staff, and faculty from various backgrounds in dental education [8,9], and to encourage DEI discussions aimed at improving cultural sensitivity within undergraduate training [10].
Along with DEI initiatives focused on people to diversify and equally represent faculty, student, staff, it is also important to employ such initiatives to make teaching content and learning strategies more relevant in dental education [11].DEI principles have been integrated into a number of medical curricula around the world, from pedagogical material to teaching cases and essays [12,13], but this seems to be under-developed in dental education generally [14].
Dental education employs an array of teaching methods, including in-person lectures, recorded lectures, and large and small group discussions of clinical problems and cases portraying dental-related scenarios, written essays and assignments, among others [15][16][17][18].In the Faculty of Dentistry (FoD) at the University of British Columbia (UBC), the four-year undergraduate dental curricula utilise various teaching methods, one being hybrid problem-based leaning (PBL) curriculum [19].In the hybrid PBL, the weekly clinical problem portrayed in the scenario is discussed in a small-group learning activity with around eight students monitored by a tutor.These discussions are supported in part by the content related to the problem at-hand delivered via lectures, allowing students to move beyond memorising the information to restructuring the facts into knowledge by combining their self-learning in small groups with the lecture material [20].Two modules that employ the largest number of PBL in the curriculum at the UBC's FoD are Fundamental Medical Sciences (FMS) I and II in Years 1 and 2 of the undergraduate dental program, respectively.Although these PBL cases were introduced in 1997, when undergraduate dental students studied the fundamentals of medical sciences jointly with undergraduate medical students, a 2010 study highlighted the need to redesign and redirect the objectives of this basic curriculum to make it more relevant to dental professionals [21].Such 2010 study led to a curriculum review which culminated with the Faculty of Dentistry teaching undergraduate dental students separately from Faculty of Medicine students starting in the 2015-16 academic year.The PBL cases have since been revised in terms of their dental and oral health relevance and content, but it is unlikely that these revisions addressed issues of diversity, equitable representation, and inclusion in regard to patient and provider characteristics, context, and treatment outcomes.Diversity and inclusive teaching using various methods and pedagogies is essential for preparing civically engaged health care providers and for creating a society that is equitable, diverse and inclusive of all people [22].It should also be reflected on the teaching material itself that we use.By doing so, we acknowledge a range of differences in patients and cases, embrace such differences, and allow these differences to transform the way we think, teach, learn and act.
The objectives of this study were two-fold: 1) to extract information from all the PBL cases at UBC's FoD curriculum in terms of the diversity, equitable representation, and inclusion of patient and provider characteristics, context, and treatment outcomes; and 2) to compare these findings with the composition of the British Columbia census population, dental practice contextual factors, and the evidence on treatment outcomes within patient care.Our research question was: "To what extent do the University of British Columbia's Faculty of Dentistry PBL cases represent the composition of the BC population in terms of patient characteristics; the context of the profession in terms of provider, dental insurance, and dental practice characteristics; and the various treatment outcomes based on the existing literature?".This study offers a robust discussion of the importance of the PBL cases representing diverse populations for a more culturally sensitive training of future dentists.

Methods
This study did not involve the recruitment of human participants, so there was no need to obtain ethical approval from the University of British Columbia's Behavioural Research Ethics Board.After gathering copies of all 58 PBL cases from Fundamental Medical Sciences (FMS) I and II modules between January and March 2023, an extraction table was developed (Table 1).The information was extracted manually by two trained researchers (LC, BB) who read each PBL case and collaborated on a single document shared on Google Workspace 1 .The information extracted was based on: • Patient characteristics (age, gender, sexual orientation, ethnicity, language spoken, and body type); • Provider characteristics (age, gender, sexual orientation, and ethnicity); • Context (type of insurance if any, type of dental practice of the provider including private and hospitals); • Treatment outcome (successful, unsuccessful).
The extraction table focused on diversity (e.g., the variety of characteristics among cases pertaining to patients, providers, context, and treatment outcomes); equitable representation (the fair portrayal of these characteristics, context and outcomes across the PBL cases); and inclusion (e.g., the extent to which these differences, context and outcomes were represented across cases).The findings were compared with the demographic composition of the British Columbia census population (note that British Columbia is a province with high ethnic diversity).We also compared the content of the PBL cases with the dental practices' ownership characteristics (sole/private, group practice, corporation, etc.), patients' ability to understand and afford care, and with the evidence of success of various treatment outcomes based on existing literature.Characteristics relating to the composition of the province's general population were obtained through official government data [23,24] and our previous work [25].All data collected were exported into IBM 1 SPSS (Version 27) software for statistical analysis.Descriptive statistics included summaries of the data in terms of means and frequencies.The Pearson's chi-square test (odds ratio) was utilised at p < 0.05.

Results
Upon reviewing the curriculum, a total of 58 PBL cases were identified for inclusion and analysis in this study.These 58 cases make-up all the PBL material available and included 30 cases for FMS I and 28 for FMS II modules; a smaller number of PBL cases exists in other modules, but were not included in this study.Table 1 shows the percentages of patients, treatment outcomes, and dental practice's characteristics portrayed in the PBL cases and contrasts this with for fillings [50] and 60% for root canal treatment over time [51] Affordability: Able to pay for the treatment provided • 13.7% of the cases (8 cases) mentioned inability to afford treatment (surrogate for not having insurance) • 16% of British Columbians cannot afford dental care, 25% in British Columbia [24] Dental practice characteristic: University dental clinic • 10.3% of cases (6 cases) were at the UBC dental clinic the British Columbia population composition, evidence of treatment outcome success rates, and the types of dental practices in the province.Fig 1 offers a comparison between those with and without insurance in the PBL cases and in the general population.Treatments involving patients without a disability were 5.74 (95% CI [1.28, 32.7], p = 0.04) times more likely to be successful than those involving patient with a disability.Cases involving patients unable to afford treatment were 2.81 (95% CI [0.42,19.21],p = 0,5) times more likely to be referred to another dentist/clinic than those able to pay/with insurance.

Discussion
This study was the first to map all the cases in the form of PBL from the two largest problembased modules at UBC's undergraduate dental program in terms of their diversity, equitable representation, and inclusion.In particular, we answered to our research question by exploring the extent to which patients' and providers' characteristics, context, and treatment outcomes were represented within the cases when compared to the population's characteristics, dental practice contextual factors and the evidence of successful treatment outcomes within patient care.We found that more work is needed in this regard.For example, the PBL cases seemed to accurately reflect the prevalence of disability among British Columbians according to its Government [26].However, this disability was mostly portrayed in terms of obesity without any attempt to discuss its interplay with disease that can lead to increased stereotypes, weight-related stigma, and body shamming as found by Hilbert and colleagues [27].
The PBL cases also seemed to realistically represent the gender (males and females) composition of the population and to emphasise that around 16% of Canadians are unable to afford the recommended dental care treatment.But in the case of affordability in particular, that percentage is much higher-25%-among British Columbians themselves who would not be able to fully afford the treatment offered and delivered within the cases [25].Also, dentists' diversity could have been implied when 23% of providers portrayed in the cases were the students themselves ("You are the attending dentist when the patient arrives. .."), representing whoever they are in terms of gender identity, race, ethnicity, and other socio-demographic characteristics.But, in general, despite efforts to include diversity, equity, and inclusion mission statements on dental school websites worldwide focused on people, PBL teaching material at the UBC's Faculty of Dentistry seems to fall short on these efforts, including equitable representation of various patients, providers and outcomes characteristics.According to our findings, there is a disconnect between diversity and inclusive teaching in the classroom and diversity and inclusive teaching in the curriculum material employed in the modules that comprise our dataset.
It is well known that problem-based learning methodology can enable students to develop superior professional skills and effective learning strategies compared with those instructed using traditional approaches such as lectures [28,29].However, the PBL cases we revised may lack authenticity in utilizing a more realistic health educational context for the students regardless of the teaching pedagogy employed, as reported by Lee and colleagues when discussing health-related training [30].
Although there is evidence that recent graduates may feel relatively unprepared [31] to perform certain clinical procedures after they graduate [32][33][34][35][36], more realistic cases are still needed to better represent patients and their care providers, regardless of clinical procedures to be performed.The technical skills required to perform a given treatment do not vary based on patients' skin colour, sexual orientation, or body type, but interpersonal skills and understanding may change based on these and other patients' characteristics including socio-economical status, race, cultural background, personal health values and beliefs, and so on.Therefore, it is paramount to have these procedures contextualized within these characteristics and patient's diverse backgrounds and contexts, and students' interprofessional skills.For example, by not fully representing the array of patient ethnicities, the PBL cases might inadvertently overlook the importance of cultural practices in shaping peoples' oral health behaviours [37,38], particularly for Indigenous Canadians [39,40] who were not represented at all in the cases.Such overlook may hinder the understanding of Indigenous cultural competency that is needed to recognize, comprehend and appreciate the values, traditions and belief systems of Indigenous peoples that may be markedly different from one's own.By not including an equitable representation of patients with sexual orientations other than straight, the PBL cases may not account for the increased health inequalities experienced by non-straight individuals [41] that make up at least 4% of the British Columbia society [42].And by not representing languages other than English or French that are spoken in the Province by many patients, the PBL cases might have downplayed the relevance of establishing patients' rapport and their abilities to fully understanding treatment options so that informed consent is indeed fully obtained [43,44].Likewise, the pedagogical opportunity afforded in PBL cases in itself can be explored, for example, by encouraging the tutors to address the biases students present while discussing the cases to better incorporate important culturally responsive information of patients.
As affordability for some remains a driver to receiving recommended dental treatment and having dental insurance is a major facilitator in doing so [45], the PBL cases should more realistically portray patients who are not able to afford dental care in the province, and who do not have insurance (Fig 1).Around 32% of Canadians and more than 30% of British Columbians have no dental insurance [25], and although insurance was mentioned in some of the cases, it was not identified as a key factor for patients obtaining the care they needed, downplaying the impact of affordability to more than 25% of British Columbians.But at the same time, the PBL cases should now better reflect the potential impact of the newly introduced Canadian Dental Care Plan [46] that is designed to help ease financial barriers to accessing oral health care for uninsured Canadian residents bellow an annual family income of less than CAD$90,000 (US$: 66,500 on May 1, 2024).
With most patients in the PBL cases being portrayed as relatively younger (less than 9% were older than 65 years), students might not fully understand the impact of aging in the provision of oral health care when almost 20% of the population is already older the 65 and some might present with systemic health issues, comorbidities and limitations [47].Although the students do learn about aging in subsequent years of their training [31,48], it is important to better represent our ever growing older adult population in all aspects of our teaching and to avoid biased views of aging that might lead to ageism and prejudices against older adults as we discussed previously [49].
Over the years the landscape of practicing dentistry has changed from the dominant and traditional model of sole providers to more group practices and even large corporations [50][51][52].In turn, the PBL cases could reflect such changes in landscape to better mediate future graduates' expectations about their working environment.The cases should also offer a more realistic expectation about successful treatment outcomes below the 90% success rate currently presented, as failures and re-dos do occur over time, are part of the practice of dentistry [53][54][55][56] and should be discussed accordingly for a more realistic practicing scenario.
Lastly, the unfortunate associations we found showing treatments involving patients without disability being more likely to be successful than those involving patients with a disability, and cases involving patients unable to afford treatment being more likely to be referred to another dentist, might send the wrong ethical and professional message.Patients with a disability and those unable to afford care already face adversities when accessing oral health care [57,58] and the association portrayed herein may not only perpetuate these experiences, but also impede efforts to teach social responsibility [17] and ethics in health care [16].
Despite its findings, this study has limitations.The focus on the PBL cases from one dental school prevents generalisations to other PBL curricula.Given that PBL cases are not the only source of learning, students might have been exposed to diversity, equitable representation, and inclusion elsewhere in their dental training which was not considered in this study.The PBL cases are facilitated by a tutor-usually a volunteer dentist from private practice or internationally trained-and we do not know if these tutors might have incorporated their diverse views when discussing the cases with the students.Whether or not patients portrayed in teaching cases are fictitious or real, they must reflect the composition and characteristics of the population graduates will serve.
As the PBL cases are being revised to better reflect these characteristics, future studies should assess the extent to which these changes impact students' understanding and appreciation for diversity, equitable representation, and inclusion in oral health care.It is also important to empower students to engage in these types of curriculum revisions aimed at improving their own education collaborative input, as suggested by French and colleagues [59], while respecting their busy schedules to avoid burn out.

Conclusions
The characteristics of the patients, practice context, and treatment outcomes portrayed in the existing PBL cases differ from the current composition of the British Columbia population, treatment outcome success, and practice context; a curriculum disconnect thus exists.Although dentists' diversity could be implied when 23% of the students were portrayed as the providers in the cases, the existing PBL curriculum are being revised to better portray the mosaic of our society and treatment outcomes.Students should have more opportunities to actively think about the barriers to care that other groups and populations face based on their inherent characteristics, and to refrain from stereotyping certain populations in practice.The PBL cases should be revised to better represent the population which most students will care for in their practices.

Table 1 . Patient, treatment outcome, and dental practice characteristics portrayed in the cases compared to the general population composition, evidence of treatment outcome success, and types of dental practices in British Columbia, Canada. Patient, treatment outcome and dental practice characteristics In the PBL cases^In the British Columbia population, in the evidence around treatment outcomes, and in the types of dental practices
• The success rate can be as low as 50%

Patient, treatment outcome and dental practice characteristics In the PBL cases^In the British Columbia population, in the evidence around treatment outcomes, and in the types of dental practices
In British Columbia, the Employment Equity Act defines visible minorities as persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in colour, and consists mainly of the following groups: South Asian, Chinese, Black, Filipino, Latin American, Arab, Southeast Asian, West Asian, Korean and Japanese.23**The acronym considers sexual orientation, gender identity and gender expression.2S refers to Two-Spirit People in the First Nation and Indigenous culture; L refers to Lesbian; G refers to Gay; B refers to Bisexual; T refers to Transgender; Q refers to Queer; I refers to Intersex, and + is inclusive of people who identify as part of sexual and gender diverse communities, who use additional terminologies.< https://www2.gov.bc.ca/gov/content/home/accessible-government/toolkit/audience-diversity.